The application will be processed once we have received and accepted
a readable copy of the requestor's current government-issued photo identification,
such as a current driver's license, passport, military ID, or state ID.

The ID must be received in our office within three (3) business days

Use one of the following methods to submit the requestor's ID

• Use a Smartphone (or digital camera), take a photo of the requestor's ID, and email to: DHHS.VitalRecords@nebraska.gov
• Use a scanner, acquire a copy of the requestor's ID, and email to: DHHS.VitalRecords@nebraska.gov
• Fax a copy of the requestor's ID to (402) 742-2385NOTE: Please enlarge 200% and lighten image before faxing.

FOR YOUR PROTECTION PLEASE USE SECURE EMAIL WHEN SUBMITTING ID.

Acceptable image formats are .JPG, .BMP, .DOC, .PDF and .TIF

Please include the Confirmation Number provided when you have
completed the application and the name(s) on the record

Please complete the form below

Full Name at Birth:(If adopted, list adoptive name.)

First Name:

*

Middle Name:

*
If no middle name, enter "None"

Last Name:

*

Date of Birth: ( Month, Day, and Year of Birth )

Date:

Month
Day
Year
*

Location of Birth:( City and County )

City of Birth:

*

County of Birth:

*

Father's Full Name:(If adopted, list adoptive father's name.)

First Name:

*

Middle Name:

*
If no middle name, enter "None"

Last Name:

*

Mother's Full Maiden Name:(If adopted, list adoptive mother's name.)

First Name:

*

Middle Name:

*
If no middle name, enter "None"

Last Name:

*

General Information

Is this the record of an adopted person?
YES
NO
*

For what purpose is this record to be used?

*

How are you related to the person named on the birth certificate that you are applying for? If this is your record, please enter 'self'

*

Comment(s):

Please re-read all the information on this form for its
accuracy.When you are satisfied that the information listed above is correct.
Click on the "Submit Birth Information" button.